Sleep Medicine: An Overview

Fraser Willsey, Sleep Specialist at The Royal shares facts on sleep, what they do at the Sleep Lab, and how to treat sleep disorders.

1. SLEEP MEDICINE:
An Overview
Fraser Willsey, BA, RPSGT
Sleep Lab Technologist
Sleep Disorders Service, The Royal

2. Why Study Sleep?
•We spend 1/3 of our lives sleeping
•1 in 7 Canadians are not getting enough sleep (Statistics
Canada, 2002)
•Severe health consequences - DEATH!
•Sleep deprivation costs
$150 BILLION/yr in lost
productivity
(Nat’l Commission on Sleep Disorders, 2003)

3. THE IMPACT OF SLEEP DEPRIVATION

4. •Challenger Disaster
•3 Mile Island
•Chernobyl

5. Purpose of Sleep
•Restorative Function
•Energy Conservation
•Immune Function Regulation
•Memory Consolidation
•Mood Regulation and depression
•Protective Mechanism

7. WHAT WE DO AT THE SLEEP
LAB….

9. What Happens at the Sleep Lab…
•ROMHC: 6 bed clinical lab, 4 bed research lab
STEPS:
1) → Referral
2) → Consultation with a Sleep Specialist
3) → Overnight Sleep Study
4) → Data is Analyzed by RPSGTs
5) → Results Appt with a Sleep Specialist

10. How Do We Measure Sleep in the
Laboratory?
•EEG – brainwaves (Central & Occipital Leads)
•EOG – eye movements
•EMG – muscle tone
•EKG/ECG – heart
•Breathing:
1)Airflow
& 2) Effort: Thoracic & Abdominal
•Blood oxygen saturation (SaO
2
)
•Snore mic.
•Digital AV recording

14. STAGES OF SLEEP
•NREM & REM
•NREM = N1, N2, N3
•Sleep Cycle
•REM increases as the night progresses
•Changes across the lifespan

15. NREM SLEEP
•N1: lightest stage of sleep
(hypnic jerks/sleep starts), dozing
•N2: Sleep spindles & K complexes
•N3 (formerly stages 3 & 4): deepest most
physically restorative stage of sleep. More
difficult to awaken from this stage. Decreases
with age.
•Breathing regular, heart rate decreases

16. AWAKE

17. STAGE N1

18. STAGE N2

19. STAGE N3

20. STAGE N3

21. REM Sleep
•Rapid Eye Movements
•Muscle atonia (paralysis)
•Dream recall
•90 minute latency
•“Paradoxical Sleep” – EEG mimics wakefulness
•Breathing irregular, heart rate fluctuates

22. REM

23. TRANSITION INTO REM

24. SLEEP APNEA

25. SLEEP APNEA
•Two Types: Obstructive & Central
•Pauses in breathing > 10 seconds in length
•Respiratory Disturbance Index: >5 hr =clinically significant
•Symptoms:

▪
Excessive daytime sleepiness (EDS)

▪
morning headaches

▪
SNORING*****

▪
pauses in breathing

▪
waking with a dry mouth

▪
nocturia

▪
Gastroesophageal reflux disease

ZZZZzzzzzzZZZZzzzzzz

26. OBSTRUCTIVE SLEEP APNEA (OSA)
•Causes

▪
Narrow Upper Airway

▪
Elevated BMI

▪
Family Hx
•Exacerbated by:

▪
Rx

▪
Alcohol Consumption

▪
Supine sleep

▪
REM sleep

▪
**Supine + REM sleep

27. Normal vs. Collapsed Airway

28. “Kissing” Tonsils

29. OBSTRUCTIVE APNEA

30. OBSTRUCTIVE APNEA, 2MIN

31. OBSTRUCTIVE APNEA 5MIN

32. TREATMENTS FOR OSA
•**CPAP – Continuous Positive Airway Pressure
•**Weight Loss - ↓ BMI = ↓ RDI
•Avoid Alcohol Consumption
•Avoid Sedative Medications
•“Snoreball” Technique / Positional Therapy
•Oral Appliance
•Upper Airway Surgery
–Tonsilectomy
–Laser Surgery
–Tracheostomy
– Uvulopalatopharyngoplasty (UPPP)

34. CPAP

35. CPAP

36. Consequences of Untreated OSA
•Memory Problems
•Depression
•Cardiovascular disease
–High blood pressure
–Stroke
–Cardiac arrhythmias

39. FASTEN YOUR SEATBELTS…
THERE’S ANOTHER CONSEQUENCE OF
UNTREATED OSA & SLEEPINESS
ANY GUESSES WHAT IT IS?

43. PARASOMNIAS

44. PARASOMNIAS
•NREM
Sleepwalking (Somnambulism)
Sleep Terrors (aka Night Terrors)
Others examples: Sleep Related Eating Disorders,
Confusional Arousals, Somniloquy
■ REM
REM Behaviour Disorder (RBD)
Measured in the sleep lab with full EEG to rule out seizure
activity

45. SLEEPWALKING
•Stage N3 (slow wave sleep)
•Common in children
•Do not awaken. Secure the environment
•No recall of a dream or of the episode
•Aggravated by sleep deprivation, stress, alcohol
•Positive family history
•Perform complex behaviours with heightened
pain threshold

46. JAROD ALLGOOD
Feb. 2, 1973 – Feb. 9, 1993

47. REM Behaviour Disorder (RBD)
•No muscle atonia during REM sleep
•Ability to act out complex dream behaviour
•Bedpartner often the “victim”
•Age of onset: 50 – 60yrs. Males
•Usually opposite of waking personality
•Case study: “baseball player” at ROMHC

48. RBD

49. REM BEHAVIOUR DISORDER

50. Treatments for RBD
•Full EEG montage during PSG
•CT Scan, MRI – r/o lesions
•Securing the environment (mattress on floor, bed
rails, restraints)
•Bedpartner sleeps in another room
•Rx

51. SLEEPWALKING vs. RBD
SleepwalkingSleepwalking
▪ ▪ Stage N3 (NREM)Stage N3 (NREM)
▪ ▪ No dream recallNo dream recall
▪ ▪ ChildrenChildren
▪ ▪ Not easily awakenedNot easily awakened
REM Behaviour REM Behaviour
DisorderDisorder
▪ ▪ REM sleepREM sleep
▪ ▪ Dream recallDream recall
▪ ▪ Adults (elderly)Adults (elderly)
▪ ▪ Easily awakenedEasily awakened

52. PLMs 2 MIN

53. PLMS Treatment
•Rx
•Iron supplementation
•CPAP if PLMs secondary to apnea

54. Restless Legs Syndrome (RLS)
•Disorder of WAKEFULNESS (PLMs = sleep)
•Subjective report of an uncomfortable sensation in
the legs while at rest
•Irresistible urge to move the legs
•Symptoms subside with movement
•“Creeping”, “itching”, “creepy-crawly”, “pulling”,
“tugging”, “gnawing”, “toothache in my legs”, “bugs
or worms crawling under my skin”
•Symptoms worse in the evening
•Almost all patients with RLS display PLMs during
sleep

55. RLS Treatments
•Pharmacological (dopamine agonists)
•Non-Pharmacological:
–Iron supplementation
–Warm bath
–Exercise
–Massage, acupuncture, relaxation techniques
–Keeping mind engaged when having to stay seated
–Eliminate caffeine and alcohol
–Bar of soap under the sheets!

56. SLEEP & MEDICAL ILLNESS

57. Normal Fibromyalgia

58. SLEEP & MENTAL ILLNESS
•Depression
–Early morning awakenings
–Short REM latency
–Increased time in REM sleep
–May mimic narcolepsy on the MSLT

59. SLEEP & MENTAL ILLNESS
•Anxiety
–Increased sleep onset
–Prolonged awakenings
–Panic attacks (with/without sleep apnea)

60. SLEEP & MENTAL ILLNESS
•Psychiatric Populations and Sleep
–Schizophrenia (apnea, sleep spindles)
–PTSD (nightmares)
–Geriatrics
–Mood disorders

61. INSOMNIA

62. INSOMNIA
•Difficulty initiating and maintaining sleep
•Early morning awakenings
•Complaint of poor, insufficient or nonrefreshing
sleep
•Impact on waking behaviour
•Sleep Efficiency < 85%
•Longer SOL (> 30 minutes), short total sleep time
(TST)

63. Insomnia Treatments
•Cognitive Behavioural Therapy
•Sleep Restriction Therapy
•Relaxation Techniques
•Sleep Hygiene
•Prescription medications

64. GOOD SLEEP HABITS
•Get up at the same time each morning. Even if
you fall asleep very late, you should still get up at
the same time each morning
•To avoid “Sunday night insomnia, Monday
morning blues”, don’t stay up late on weekends
and then sleep in
•Go to bed only when sleepy
•Develop a relaxing pre-sleep ritual such as
reading, taking a bath, brushing your teeth, etc

65. GOOD SLEEP HABITS
•Use the bed only for sleep and intimacy
•Nicotine is a stimulant. Try not to smoke near
bedtime
•Hunger may disturb sleep. Perhaps try to have a
light snack before bed. A glass of warm milk
contains a natural sleep aid
•Exercise regularly. Get vigorous exercise either in
the morning or the afternoon and do only mild
exercise two to three hours before bed

66. GOOD SLEEP HABITS
•Don’t stay in bed if you can’t fall asleep within 15
minutes. Tossing and turning will just make you
more frustrated
•Get as much sleep as you need, but no more
•If you find yourself worrying at bedtime, set aside
a “worry time” – perhaps 30 minutes in the early
evening to write down both problems and
solutions

67. Zzzzzz QUESTIONS?? Zzzzzz
[email protected]